Addressing Systemic Failure at the Nation’s Hospitals

By ThinkReliability Staff

A Medicare analysis (see the news report) has shown that a small (but significant) group of hospitals have much higher than average death rates from pneumonia, heart failure, and heart attacks.  Additionally, the study found that one in four heart failure patients (and a similar but smaller percentage of pneumonia and heart attack patients) have to return to the hospital within 30 days.

Hospitals are in the business of solving problems.  So, what do the results of this study tell us about problem-solving?  Statistics like this point to a systemic failure.  Systemic failure indicates an inability of the system (in this case, hospitals) to achieve their goals (improving patient health).  Although statistics can help determine if there is a problem, statistics themselves do nothing to solve the problem.

A root cause analysis investigation can be a useful tool to determine the causes of systemic failure.  The investigation can be performed by anyone with the authority to effect change – for example, Medicare itself could perform the analysis, with results and associated suggestions for improvements being provided to its associated hospitals.  Or, an individual hospital can perform an investigation itself, using its own data and experience.

This seems like a monumental task – just considering one in four heart failure patients results in a staggering number for any hospital.  However, an investigation of systemic failure does not require an analysis of each individual case.  Instead, begin with one specific case.  Dig up all the information on one patient who returned to the hospital after treatment, and perform a comprehensive root cause analysis investigation on that case.  Because this specific case is part of a systemic issue, properly implemented action items (solutions) will improve the care at the hospital as a whole, thus reducing the number of cases that make up the systemic issue.

Once this has happened, the job isn’t done.  After solutions are implemented, their effectiveness must be verified.  For large systemic issues, implementing action items from one investigation may not be sufficient to “solve” the problem (allow the hospital to achieve its patient health goals).  If this is the case, other specific incidents can go through the same root cause analysis investigation process, one at a time, until the implemented solutions allow the hospital(s) to operate in a satisfactory manner.